A patient in ICU was started on atracurium infusion. He developed seizure on day 3. What is the most likely cause?
**Core Concept**
Atracurium is a non-depolarizing neuromuscular blocking agent that undergoes Hofmann elimination, a chemical process that leads to the breakdown of the drug. This process is temperature-independent and occurs in plasma. Atracurium's active metabolite laudanosine can accumulate in patients with renal or hepatic dysfunction, leading to central nervous system (CNS) toxicity.
**Why the Correct Answer is Right**
The patient developed seizures on day 3 of atracurium infusion, likely due to the accumulation of laudanosine, a CNS stimulant. Laudanosine is an active metabolite of atracurium that is eliminated primarily by the kidneys. In patients with impaired renal function, laudanosine can accumulate and cause CNS toxicity, manifesting as seizures.
**Why Each Wrong Option is Incorrect**
**Option A:** This option is not applicable to the scenario as atracurium does not cause seizures through this mechanism.
**Option B:** Laudanosine is the correct answer, not histamine, which is associated with anaphylaxis and hypotension.
**Option C:** Atracurium does not cause seizures through histamine release; this is more characteristic of certain antibiotics.
**Option D:** This option is not relevant to the scenario as atracurium does not cause seizures through this mechanism.
**Clinical Pearl / High-Yield Fact**
In critically ill patients, neuromuscular blocking agents like atracurium can have unique elimination pathways, leading to the accumulation of active metabolites like laudanosine, which can cause CNS toxicity.
**Correct Answer: B. Laudanosine**